Small bowel obstruction secondary to adhesions with a funny 'twist'
32 year old who had surgery for ectopic pregnancy 8 years ago and a second surgery 5 years ago (indication not clear) , presented with colicky abdominal pain of a month duration . this wa initially associated with adbominal distension , vomiting and constipation. She was seen on two ocassions at district hospitals and managed conservatively with spontaneous resolution on each ocassion. She however developed another acute episode 3 days ago and was refered by the attending physician to KATH.
Examination : dehdrated , ill looking , afebrile . Abdomen was distended with but moved with respiration. Mild tenderness on palpation, high pitched bowel sounds. DRE- empty rectal ampulla.
Diagnosis : Intestinal obstruction secondary to adhesions
Investigation : Plain erect and supine ABD XR showed distended loops of small bowel.
FBC -normal, elctrolytes showed potassium of 2.1mmol/l
Nasogastric tube passed to decompress the abdomen, fluid resuscitation commenced and potassium corrected to 4.5mmol/l. decison taken to do exploratory laparotomy due to the frequency of obstruction within the last 4 weeks
Surgery : Exploratory laparotomy
Intraoperative Findings :
1. constricting band found 60cm proximal to ileocaecal junction
2. Four complete clockwise small bowell turns around the constricting band
3.Loop of small bowel attached to the fundus of bladder and anterior abdominal wall at the pubicregion.
4.Enlarged mesenteric lymph nodes close to the contricting band
5.No strangulation of bowel seen.
Intraperative detais : Constricting band resencted with a sgment of small bowel drained by the mesenteric lymph nodes and end-end anastomosis done. loop of small bowel attached to the anterior abdominal wall released
Post operative state : Patient is clinically stable and ambulant
Credits : Drs Michael Adinku (General surgeon), Richard Ametih (Resident)